R-5531 (2) APPLICATION FOR CITY of CUPERTINO
NUMBER R- 5531
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ?
(:)C>L, 70 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME—.4" YES ❑ Ifyes-Imbly standis
that. ClassA
—/T1 1 — YY roof assembly is require i
J , NO/LI\ InlUal LC.B.O.q
ADDRESS �2 �(J N�N. � �� EXISTING ROOF COVERING
• PHONE - "Z. NUMBER OF EXISTING COVERINGS
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS //, C ` TYPE OF ROOF COVERING
CITY&ZIP /�/ /` l��LdJ_f(L
EXISTING
PHONE E BUILT-UP ROOF ❑
LICENSE (�7�"^ —7 7 6 ASPHALT SHINGLES ❑
NUMBER J .� / 7
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 o e Business and Professions Code,and my license is In full force and A
effect. WOOD SHINGLES
License Class 3S Lic.Number �Oi o
_ Zl ZTHER (SPECIFYZ, FV/�A
Data ContCon111 nF -V
OWNER-81.111 N PROPOSED nvF�, V
hereby ellBu that am exempt from the Contractor's License Law for the following reason. 'I
(Sec.]0315,r,Improve,
and Professions Code: Any city or county which requires also e permit to UNt
construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF h®1'
applicant for such permit toa lila a signed statement nci h Is licensed pursuant to the provisions YO
of the Contractor's License Lew(Chapter h(commencing with Section the b of Division 3 of the
• Business and Professions f Coda)or 1311 he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any ltyof oft more thanlive Section hundred
byany s($5 0).nt lorepermit subjects the applicant to
a civil penalty owner not more than five hundred dollyeesrw(h wg a WOOD SHAKES
❑Irksndthe f thestructure
I not Iy,or my tended employees wages as(Sec.their 44,ole compensation,sand
Profes-
sions
r will leis I/
the work,end the structure Is not Intended or offered for sale(Sec.owner
of Business antl builds
or
Code:Th Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,ing or improvement provided that ❑
suchimprovements
ars not platin,tended oro fferedforsale.It,itl however,the enof prviimprovement
nsold tbuild ori prove for completion,the ownerbuiltlerwill have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve icor purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a connections)licensed pursuant to the Contractor's License Law. PROVIDE III INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT F
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty,of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, B I Id
as provided for by Section 3]00 of the Labor Code,for the performance of the work for which this l
permit is Issued ( r�OQ• �J
❑1 have an ill mai m Worker's Com nsation Insurance,as required by Section 3700 of . '12J- 7 / Sal
the Labor Cod for t perform a of work for which this permit is issued.My Workers
'Compensntion s e carri nd Pol y number are: Total
{ 7
Carrier Poucy No.l. ��J f PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMP ObN FROM WORKERS'
COMPENSATION INSURANCE N.00
(This section need not be completed if the permit Is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roof^shalrbe inspected prior to any roofing material being
Ionia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE oshoulecome
subject IO the OWorrkers C mpensal'on proviAPPLICANT. If,after sions ofethelLabor Code,s Crtifcate of yolu mustufothwitlhUcomply Applicant understands and will comply with all non point
with such provisions or this permit shalCbe deemed revoked. sour egulationS.
I certify that I have read this application and state that the above information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and A roof ve gs to be class"C"or better
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. 7�n
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City In consequence
of the granting of this permit. NATO OF APPL CANT DAT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
•
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP- DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY _—
SUBJECT: PI—OOFNG POLICY FOR T"ram: CITY OF CUPERTNO BUILDNG DEPART'IENT
PRIOR TO ISSUe\-NCE OF PER�,ai AIND D'S 'ECTION
e, you must agree to comply %vith U.E.C. s=tandards and maniac-yrcrs sec's
1. Prior to permit isstat c
on re-coling.
2. Ne, roof coveringsw shall not be applied theut first obtaining all it option and wr sea approval
from the building in_,e•_:pr. A final inspection and aooroval shall be obtained from the building
inspector when the re.cofing is completed.
3. All types of roof shall be inspe-ted prior to any roof being installed.
4. In order to receive a final,you must complete steps 1,2, and 3.
1,) Preinsectioa or tear off approval.
2.) In progress inaection approval.
3.) Final insr_tion approval.
a.) Ocem*01e smoke detector veriz=tien
• b.) Spark arrestor installation
3. . If plywocd is installed,a plywood nail ince,-'ion is required.
6. If any roof is applied without first obtaining an inspec.ion, you will be required to remove all nc v
material down to the shmtUng and a building inspr in-
7,e--will ine_.all sheathing at that time.
WE UNDERSTAND Tac ABOVE POLICY ON REROOFING AND WILL COMPLY W1721 TfiE
POLICY
EO AEOWYERS NAME:
P_DDRESSs`
REROOFING COMPANY NANT:
APPLICA`tTS SIGNATURE:
CITY OF CUPERTINO
BUILDING DEPARTMENT
•
Reroof/winwdrd